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Articles, Essays, Thoughts

Doctor’s dilemma in Cavan

By Colman Cassidy, Hibernia, 7 June 1979

Cavan County Surgeon, Mr. Boulos Hanna, cleared of culpable negligence in the care and treatment of his patients by a three-man team of eminent doctors, has as yet been given no firm indication of when he can return to work. Egyptian-born Hanna, now an Irish citizen, has already been “absent by mutual consent” for two months, pending the outcome of this report. But since his exoneration he as been warned that the feeling against him among nurses at Cavan surgical hospital is so strong, that he cannot return to work – for at least six months.
The contents of the report and its recommendations are not known – beyond a brief statement exonerating the county surgeon read to the May meeting of the North Eastern Health Board by Barry Segrave, the CEO. It is said Mr. Hanna would be granted ‘study leave’ and be absent for about six months. In the meantime, a second surgeon would – hopefully – be appointed and a locum surgeon.
The inquiry was initiated by the CEO in February into the care and treatment of 14 patients under charge of the county surgeon – to include ‘any relevant matter as a consequence of any transfer of these patients to another hospital for care and treatment’. The three men appointed to carry out the investigation were Mr. James Lavelle, consultant surgeon and a member of Comhairle na nOspidéal, Dr. Stanley McCollum, Regius Professor of Surgery, TCD and Dr. P.A. Jennings of the Department of Health. It is understood that the names of all but three of the cases to be reviewed were submitted by nurses from the surgical hospital.
Boulas Hanna arrived in Cavan in 1975 with an impressive list of qualifications. He was a fellow of the Royal College of Surgeons in both Ireland and Britain. He had qualified as a doctor in Cairo in 1958; his father was a wealthy Egyptian businessman and he was brought up in the Coptic faith. He had been a surgeon-registrar at Letterkenny General Hospital and surgeon-registrar and tutor at St. Finbarr’s, Cork. He was a registrar at Nenagh and later a consultant at Cashel before his appointment to Cavan – against competition from 17 other applicants. He is a Fellow of the Royal Academy of Medicine in Ireland.
At once he inherited a difficult situation. The former county surgeon, Mr. P. Maloney, had relied heavily on the nursing staff for the everyday running of the hospital; nurses had been given a great deal of autonomy. It is alleged that the nurses’ resentment against Mr. Hanna dates from the time the new surgeon began to tighten up on discipline – or, more accurately, to re-arrange work schedules to achieve maximum nursing coverage in the theatre and for post-operative care; he beseeched the health board for more nurses, but to no avail. Then he introduced an appointments system for outpatients; this was unheard of in Cavan, where 70 or more patients would attend the surgeon’s two-hour clinic on market day, an impossible situation.
Mr. Hanna’s methods were in sharp contast to those of his predecessor, who is said to have had a ‘winning way’ with the nurses – and natural charm. The nurses found the new surgeon off-hand and abrupt. Hanna, himself, insists that he was always courteous and civil to the nursing staff. There is little doubt that he laboured under the dual handicap of not being Irish and speaking with a marked foreign accent. Both he and his English-born wife, May, believe that he has been discriminated against in Cavan on racial and religious grounds.
In 1977 the nurses complained of the high rate of wound infection in the surgical unit and the NEHB received a report from them calling for a sepsis survey of the hospital. The Cavan surgical – in contrast to the medical unit two miles away in Lisdarn – is a creaky old building, more than 150 years old. It was condemned in 1935 and five years ago the service staff walked out because their union, the ITGWU, said it was not fit for human habitation – leaving the nurses and doctors to fend for the patients, themselves. Work on the construction of a new surgical unit adjoining the medical hospital in Lisdarn is about to commence.
In the event, Dr. Ellen Morehouse, an eminent bacteriologist, was called in by the health board not to to carry out a sepsis survey, she says, but to examine the theatre and recommend improvements, where necessary – as the NEHB had money earmarked for this purpose. What she found did not alarm her: a new theatre was built and dressing-rooms installed. When it was finished she ‘sampled the air’ and gave the theatre the all-clear. Dr. Morehouse had no grounds for apprehension, she says, about infection levels in the rest of the hospital.
Not all nurses were opposed to Mr. Hanna or the new disciplinary regime he sought to introduce. One senior nurse, at least, had the utmost faith in the new county surgeon. Her two daughters had attended him and one had undergone surgery. This woman had worked in the Cavan surgery unit for seven years, but left the hospital about two years ago.
What happened after the ‘sepsis survey’ is not too clear, since the Cavan nurses and even the Irish Nurses’ Organisation will make no comment. One thing is clear, however: complaints against the county surgeon multiplied until in September 1977, the hospital programme manager, P.J. Clarke, decided it was time to act. But Clarke – an accountant – was not considered qualified to report on a surgeon; that inquiry fizzled out. Later on, Mr. James Lavelle, the consultant surgeon at Navan, started his own inquiries, but then decided to give up. He was a member of the three-man team appointed by the CEO in February.
Although Boulos Hanna has now been cleared of culpable negligence in the treatment of patients under his charge, there are still some clouds on the horizon: several legal actions are pending ‘against the health board, its servants or agents’ – from patients or the relatives of patients treated at the Cavan surgical unit. One example is that of John Farrelly, who was admitted to the surgical unit on August 21 last and operated on for appendectomy by a junior hospital doctor – assisted by the county surgeon.
Twenty year old Farrelly complained of a pain under his left breast, three days after the operation. He was admitted to the Richmond Hospital, Dublin (St. Laurence’s) on 2 September. His letter of referral stated that an acutely-inflamed pre-gangrenous appendix had been found. Post-operative progress was reported as satisfactory – for four days. It then deteriorated, there was vomiting and diarrhoea and his abdomen was distended. Everything possible was done to save his life, according to the doctor’s report, but he died on September 17 from acute appendicitis, peritonitis, sepsis and toxaemia. His sister, Helen Dunne, is taking an action against the NEHB on behalf of the parents. She has lodged a formal complaint with the Minister for Health and was advised by his Department that the matter had been referred to the CEO, who had been asked to furnish a report. Significantly, this was before the CEO’s statement at the board meeting exonerating Mr. Hanna. John Farrelly’s case was one of the 14 considered by the working party.
The CEO’s statement, in addition, implied that the working party had found that management support, communications and public confidence in the Cavan surgical unit left much to be desired.
There have been no operations at the surgical unit since mid-March. There was talk of a locum from Monaghan, but the GPs intervened; all medical advice is against cross-cover of this kind because Monaghan is considered to be too far away. In his statement, the CEO referred to public confidence in the hospital: it would help greatly if there was a second surgeon – and a locum; every effort is now being made to fill these posts, he said, and it is hoped that a permanent second surgeon will be appointed shortly.
In the long-run, although under the Health Act 1970 the CEO is not obliged to publish the full report, he might find that the quickest way to restore confidence would be do do just that – however painful it might be for all concerned.